If their genes walk them to the edge of the cliff, their lifestyles send them tumbling over the edge, or so goes the thinking among those who study the health of South Asians.
A bounty of research suggests this group is at greater risk of developing diabetes – about three to five times that of the Caucasian population. Rates of hypertension and heart disease are also higher. While genes cannot be changed, lifestyle modification has become a priority for health-care practitioners and new community organizations that serve ethnic groups – in particular Chinese, Afro-Caribbean and South Asian populations – with elevated rates of chronic disease.
The South Asian Professional Network for Health Awareness launched an action plan in Toronto last month to reduce levels of diabetes, hypertension and heart disease among its high-risk population. Also in the Greater Toronto Area, the Regional Municipality of York granted a local organization $45,000 last month to create healthy eating programs targeting the Chinese population.
But practitioners of these programs have found it's not as easy as asking patients to swap basmati rice for brown, or pickled carrots for raw ones – that the principles of cultural accommodation extend to discussions about diet and nutrition. What many consider to be basic diet modifications can overlook the ties between culture and food – ones that link hefty portions of rich, fatty foods with economic prosperity and refined grains with purity.
In North America and Western Europe, lower socioeconomic brackets tend to be the hardest hit by chronic disease due to a diet high in fat, sugar and sodium. But in many parts of South America, Africa and Asia, it's the middle class that is the most afflicted by chronic health conditions. Foods that are higher in fat tend to be more expensive and their presence at the dinner table reflects a higher socioeconomic standing. And while immigrants are typically healthier than their Canadian-born counterparts when they first arrive – what's known as the "healthy immigrant effect" – studies suggest that after living in Canada for a few years, immigrants lose that edge.
Cooking traditional high-fat, high-sodium dishes is also seen as a means of cultural preservation, says Mustafa Koç, the founding co-ordinator of Ryerson University's Centre for Studies in Food Security.
Michelle Ladha can relate. The 35-year-old purchasing co-ordinator in Richmond Hill, Ont., says preparing Indian food – which her East African parents of Indian ancestry always cooked – is a way to share her roots with her family. "Any Indian [dish]you'd think of, we'd make it," she said. "Every other day there's always a curry in the house."
Priti Chawla, the director of the SAPNA, says many cultural factors are closely tied to food in the South Asian community and pride often blocks positive change. If a guest turns down chai with sugar in favour of water, the host could see it as disrespectful; if rice is prepared without salt, it's a sign of low socioeconomic status.
Family Lifestyle Community Services in York Region notes that many unhealthy cooking methods have persisted in Chinese culture for generations: Vegetables are braised so long they lose the bulk of their nutritional value and because few homes in China have the space for ovens, most meat is cooked by frying in butter or oil. The organization's staff hope to overcome those habits with cooking demonstrations and health seminars.
All of these cultural factors mean that doctors have to have a more nuanced approach when counselling patients about low-fat diets, Ms. Chawla says. Failure to do so can mean inaction on the patient's part. The authors of a 2008 study published in the Canadian Journal of Diabetes that cited "poor rates of compliance" among South Asian diabetics when it came to diet modification said more "structured, culturally and linguistically relevant" programming was needed.
Colin Saldanha, a Pakistan-born Mississauga family doctor who treats many South Asian patients, has taken up the cause. He has met with dozens of family physicians, nurses and dietitians throughout the Greater Toronto Area who treat South Asian patients to counsel them on strategies.
"We have to say in public-service announcements that when you're entertaining people, you don't have to put these big, oily foodstuff on the table to equate it with generosity," Dr. Saldanha said.
It was news to a lot of the doctors Dr. Saldanha advises that there are traditionally long gaps between meals because dinner takes a while to prepare and children wait until the whole family is ready before they eat. Doctors also asked for advice on ingredients they could recommend to patients that would have a degree of familiarity, such as whole-wheat flour imported from India.
When Ms. Ladha decided to switch to a healthier diet a few years ago, she signed up for Weight Watchers, but soon realized the points system didn't accommodate her diet of fried foods – samosas, kebabs, cassava and pakoras – or the curries made with fatty coconut milk and filled with vegetables cooked in clarified butter.
"When you have Indian food, your points rack up because you have oil, you have butter, you have this. One dish of coconut curry puts you back for the day," she said.
She hired dietitian Anar Allidina, who specializes in South Asian nutrition, to help her modify recipes, rather than overhaul her diet. She now uses buttermilk as a replacement for coconut milk in curries and satisfies cravings for deep-fried samosas by eating pappadums with lean ground beef. She hopes to set her family on a healthier path than the one previous generations followed.
"My husband's father, he's almost 300 pounds," she said. "I see my husband doing the same habits as him and that's going to lead to no good."
Annie Chung-Hui, a registered dietitian at South Riverdale Community Health Centre, shares Ms. Allidina's philosophy, modifying traditional recipes for her Chinese immigrant clients and holds cooking demonstrations at the centre.
"The physicians say limit your salt intake and they send the patients home," she said.
Even the widely accepted recommendation among dietitians to divide a plate into one-quarter protein, one-quarter grains and one-quarter vegetables exposes a blind spot in our thinking, said Ms. Chung-Hui, who is of Chinese descent herself.
"When you work with Chinese people, it doesn't work that way. They're eating from a bowl."
The prevalence of Type 2 diabetes among Ontario women who have immigrated from different parts of the world:
South Asia: 12 per cent
Latin America and Caribbean: 11 per cent
Sub-Saharan Africa: 8 per cent
North Africa and Middle East: 7 per cent
East Asia and Pacific: 6 per cent
Western Europe and North America: 5 per cent
Source: Centre for Research on Inner City Health, St. Michael's Hospital published 2010